What is the treatment for necrotizing fasciitis of the eye?

Treatment of Necrotizing Fasciitis of the Eye

Immediate surgical debridement combined with broad-spectrum antibiotics is the definitive treatment for necrotizing fasciitis of the eye, as delay in treatment significantly increases mortality risk. 1

Diagnosis

Early recognition is critical but often challenging due to the initially non-distinctive appearance. Key diagnostic features include:

• Severe pain disproportionate to clinical findings 1
• Failure to respond to initial antibiotic therapy 1
• Hard, wooden feel of subcutaneous tissue extending beyond visible skin involvement 1
• Systemic toxicity with altered mental status 1
• Edema extending beyond cutaneous erythema 1
• Crepitus (gas in tissues) 1
• Bullous lesions or skin necrosis 1

While imaging studies (CT, MRI, ultrasound) may help identify fascial involvement, they should never delay surgical consultation and intervention 1. Clinical judgment remains the most important diagnostic element 1.

Treatment Algorithm

1. Surgical Management (Primary Intervention)

• Immediate aggressive surgical debridement of all necrotic tissue 1
• Return to operating room every 24-36 hours for repeat debridement until no further necrosis is evident 1
• Periorbital necrotizing fasciitis may require extensive subcutaneous debridement with sparing of overlying non-necrotic skin 2
• In severe cases, orbital exenteration may be necessary 2

2. Antimicrobial Therapy

For polymicrobial infections (most common in periorbital region), use one of the following combinations:

• Vancomycin, linezolid, or daptomycin PLUS one of the following: 1
  • Piperacillin-tazobactam
  • A carbapenem (imipenem-cilastatin, meropenem, or ertapenem)
  • Ceftriaxone plus metronidazole
  • A fluoroquinolone plus metronidazole

For Group A streptococcal infections (common in periorbital cases):

• Clindamycin PLUS penicillin 1

Duration: Continue antibiotics until no further debridement is needed, patient shows clinical improvement, and fever has been absent for 48-72 hours 1

3. Supportive Care

• Aggressive fluid resuscitation (wounds discharge copious amounts of tissue fluid) 1
• Intensive care management for patients with sepsis or systemic inflammatory response 1
• Hyperbaric oxygen therapy may be considered as adjunctive treatment 3

Prognostic Factors

• Early diagnosis and treatment are the most critical factors affecting outcomes 4
• Mortality rate for periorbital necrotizing fasciitis is approximately 14% 4
• Risk factors for poor outcomes include:
  • Delay between symptom onset and treatment 3
  • Advanced age 3
  • β-hemolytic Streptococcus as causative organism 4
  • Diabetes mellitus (associated with higher amputation risk) 5

Microbiology

• Periorbital infections are commonly caused by:
  • β-hemolytic Streptococcus alone (50%) 4
  • Streptococcus with Staphylococcus aureus (18%) 4
  • Polymicrobial infections with both aerobic and anaerobic organisms 1

Complications

• Visual loss may occur due to inflammation spreading along eyelid fibrofatty-fascial tissue planes into the orbit, causing perivascular inflammation, thrombosis, and ocular infarction 2
• Eyelid reconstruction with skin grafts may be necessary to prevent cicatricial lid retraction, lid malpositions, and lagophthalmos 6

Multidisciplinary Approach

A multidisciplinary team including ophthalmologists, infectious disease specialists, intensivists, and plastic surgeons is essential for optimal management of these complex cases 1, 3.